It is now recognized good practice to inform cancer patients about the implications of their therapeutic plan including the risks to their future fertility. The possible loss of reproductive ability is recognized as a major concern of such patients, or of their parents in case of children with a diagnosis of cancer. This implies a duty of information concerning the advantages and risks of the appropriate method of fertility preservation, dependant amongst others on the patient’s gender and age, and current state of health. Thus, it should be part of their counselling about treatment options.
An ethical analysis implies considering first four main principles,1 including the respect of patient’s autonomy, the beneficence and non-maleficence of the proposed procedure, and justice. The first principle depends on good information of the patient, the second and third mean doing as much good and as little harm as possible in therapy or steps taken for their future wellbeing, and are patient-centred. The fourth principle, justice, entails treating patients according to their needs with equitable access, and depends on health services and their funding. It is a symbol of society’s regard to a group of similar patients, and has both societal and political aspects. Thus unequal access, the main current problem in fertility cryopreservation, challenges the principle of justice.
In practice we can apply the four principles to most clinical cases, but also have to distinguish the particularities of various scenarios which depend both on the age of the patient and their couple status at the time of the offer to cryopreserve. Furthermore, specific ethical considerations pertain to the nature of the material to be held, whether gametes, embryos or reproductive tissue for future self-use; to the gender differences and sexual maturity; to the time limits of use of the material including posthumous use; and the possible future help of collaborators such as gametes donors or surrogates, which may be needed after radiotherapy damage to the uterus or hysterectomy. This is all complicated further by the possible need to prioritize the immediate cancer treatment which some patients may not wish to delay.
GENERAL ETHICAL PRINCIPLES
The respect of patients’ autonomy is a straight-forward principle, which means that the patient decides, after being informed of all relevant aspects of the offered evidence based procedure, whether to pursue this or not. In legal terms, this is the key to consent as long as the patient has capacity to understand. What makes this more complex in practice is that the patient may be single or in a couple, although legally only the patient may consent to the fertility preservation. For instance, a woman may freeze her oocytes thanks to the improved outlook with vitrification, an ultrafast technique which is much more efficient than the previously used slow cryopreservation. This has been used since the early/mid 2000, and results ...